'Only mugs work in commissioning’: tackling the management brain drain
Of all the postgraduate courses in the country, places on the NHS management training scheme are among the most fiercely contested.
Despite anti-manager rhetoric spewing from media and politicians, the scheme attracts thousands of applicants, approximately only 1 per cent of whom make the grade.
What do these bright young things want to do with their careers? Anecdotal evidence suggests the majority would like to run hospitals. No surprise there, the appeal of being captain of an NHS flagship has and always will be strong.
However, one commentator made the point rather more starkly to HSJ this week: “Only a mug works in commissioning. Provision means higher pay, less reorganisation, less abuse from politicians and a safer job.”
The continuing relative lack of enthusiasm to work in commissioning should alarm the Department of Health and those leading clinical commissioning groups in particular.
Provision of more care outside hospital walls is required to meet changing patient needs and, in some cases, to deliver efficiencies. Strengthening commissioning is necessary to ensure the NHS plans and purchases healthcare in a way that is fit for purpose and, as far as possible, future proof.
So should we be reassured by the NHS Top Leaders list, which includes around 400 staff who work for primary care trusts and strategic health authorities?
The first thing that should be taken into account when making that judgement is that it is an odd list. Meant to name those likely to have the greatest influence on the NHS’s future, it features, to date, fewer than 50 GPs among its 918 members. An eyebrow must also be raised at any list of “top” leaders which requires Gareth Goodier, chief executive of Cambridge University Hospitals Foundation Trust, to undertake an assessment to achieve a place. His omission, along with others, undermines the list’s credibility. However, the make-up of the list does suggest a reservoir of talent from which CCGs and the NHS Commissioning Board can draw. Unfortunately that reassurance is largely illusory.
One very senior industry watcher describes the brain drain of the most sought after staff from commissioning to the acute sector, especially to foundation trusts, as “horrible”. One particularly hard pressed region has already lost two thirds of its commissioning talent.
The rush to the provider sector is being led by finance staff. Other reports reach HSJ of PCT chief executives and other directors applying for non-board posts at provider organisations. FTs are building from a position of strength, having raided the private sector as well as commissioners to build their “business development” teams over recent years.
Staff are moving partly as a result of the uncertainty rife in the commissioning sector, but there is another reason: pay.
Health secretary Andrew Lansley is talking up CCGs, and by inference the commissioning board, as the main drivers of NHS improvement. However, management cost allowances will restrict CCGs’ ability to pay the going rate for the best staff. The problem will be even more serious for the board, with the ridiculous upper benchmark of the prime minister’s salary likely to have a trickle-down effect of suppressing reward throughout the organisation’s hierarchy.
Across whole swathes of the NHS, commissioning activity is now being driven by deputies and those “acting up”. Unless an effective way is found of retaining talent in commissioning, both CCGs and the board may find the cupboard bare when they attempt to build their teams.
There is one area, however, where talent is being retained on the commissioning side of the fence – the private sector. Many of the businesses looking to provide commissioning support are able to match foundation trusts in pay and opportunities. This trend is highly likely to shape the nature of commissioning support regardless of the preferences and prejudices of CCG leads.
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Readers' comments (26)
Anonymous | 29-Sep-2011 10:58 am
perceptive and starkly accurate assessment. I'm working in a CCG, but if I look across to my PCT, there are:
- only 2 substantive Board postholders, with the other roles being filled by an oft-changing array of interims, who won't have the same buy-in to the organisation. Conitnuity in decision-making processes is rubbish
- a significant number of people at all levels leaving, either through VR or to other NHS and non-NHS employers. By the end of next month, we'll have lost another 2 senior officers. The skills gaps are accumulating rapidly, as is the loss of experience and knowledge
- posts in the new CCG and Cluster certain (on the basis of material out for consultation to staff) to be at least 1 or 2 bands lower than currently. No change in responsibilities, just pay
- we do have similar issues in our main providers, but to nowhere near the same extent
- we've had extensive dealings with the private sector over the last year. Very able people, but all they've really been doing is critiquing and editing wotk that's been done in the PCTs. It's pretty routine stuff. Anyone who thinks they could pick up the complex local issues, QIPPs and partnerships and deliver what we're doing now on the basis of their existing skills and knowledge pool is dreaming. And it doesn't matter what they want pay their staff, our CCGs will have fixed cash. That's going to mean being able to buy less time from inexperienced people. I know how I'd feel about that at a CCG Board table
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Anonymous | 29-Sep-2011 11:22 am
I must be missing something here - if private sector providers of Commissioning support are able to pay so much more than their NHS equivalents which are having to tailor salaries to the levels of funding available to CCGs via the management allowance, how will CCGs be able to afford to use them...? Surely these Private Providers will not be able to pay decent salaries and also turn a profit as there will simply be insufficient commissioning support funding in the system..?
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Anonymous | 29-Sep-2011 12:12 pm
Anon 11.22am having worked in the NHS and the private sector, I agree that salaries are significantly above anything on A4C (plus performance related pay and other perks) - but they don't pay you based on the funds they get from CCGs. Most have lots of other products and services to offset risk (so e.g. if they don't win commissioning support bids, then they can be working with pharma on supply chain or something completely different) - and can also use contractors a lot more, so when work stops, they stop paying. Some are even looking at different business models with the NHS (like joint ventures or strategic alliances) so they can TUPE over existing NHS staff, keep their knowledge and corporate memory but also retain the business....
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Anonymous | 29-Sep-2011 1:33 pm
So as an ex-management trainee working in commissioning, am I good place or bad place?!
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Eric Hemming | 29-Sep-2011 1:43 pm
Pay is the key issue, but this is nothing new. Is it not also one of the fundamental reasons why transfer of emphasis from secondary to primary care has consistently failed? With some notable exceptions have not hospital providers always been able to attract the strongest managers? Money talks.
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Richard Russell | 29-Sep-2011 1:45 pm
I have worked in an Acute, SHA, PCT and DH setting and now am freelance employing two staff.
Our offices are cheap, our overheads non existent and our salaries comparable with the NHS. Actually they may be slightly lower but we don't need to have a policy like "Improving Working Lives" because we automatically work to those kind of values making for a very nice working environment.
Virtually all of our clients are NHS organisations and they stay with us because we are excellent value for money.
We help NHS staff do the work rather than doing it for them - means that the NHS staff keep the expertise they gain from doing the work and it means they only spend on us a small amount for expert support.
The point I am getting to is that I think the NHS can lead to a fantastic career, lots of variety and actually commissioning can be an amazing place to work. Plus the private sector can be cheaper than NHS equivalents although a big caveat as it depends on the culture of the private company.
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Anonymous | 29-Sep-2011 2:02 pm
... given what HSJ charge for advertising, I'm not sure they'll appreciate that!
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Anonymous | 29-Sep-2011 3:37 pm
Anon 12.12
you're describing the existing consultancy model - it's a different world coming in and doing a bit of information crunching, producing a few charts and drawing a few conclusions, than developing long-term relationships with relevant local stakeholders, unpicking extremely complex local issues and developing viable long-term solutions. To do that you need long-term dedicated staff time, often of less skilled people than private sector providers employ, but people who understand the inertia that often exists in local healthcare systems and how to go about unblocking it over time, slowly and painstakingly and usually very painfully. Which is exactly what PCTs have been doing over the years and is a function which will have no appeal or profit potential for private providers.
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Anonymous | 29-Sep-2011 4:52 pm
Going from NHS commissioning to a private company it doesn't take too long to realise that any potential development or lead starts with one simple question: where's the profit? That may also be about developing a relationship which leads over a longer period to generating earnings, but no-one surely can be fooled by the involvement of McKinseys, PwC or any other company. In retrospect, when I think of the areas of work that I used to get involved in while in the NHS, sometimes I may have been better off being more discerning and asking why exactly are we doing this.
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Anonymous | 30-Sep-2011 9:02 am
Working in the acute sector does generally pay more, but also often involves very excessive working hours with regular 7.30 and 17.30 meetings which plenty of people working in commissioning wouldn't consider worth the extra few thousand a year after tax..
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Patrick Newman | 30-Sep-2011 9:29 am
The commissioning side is becoming weaker at the same time the providers - especially the FT's are gathering strength and 'mass'. CCG's will be forced into sharing privatised support - may that's the agenda!
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Anonymous | 30-Sep-2011 10:51 am
anon 9.02
Don't know what colour the sky is on your world, but as a commissioner I'm working closely with GPs and other local stakeholders.
That means my diary is chock full of early and late meetings which are ahead of or after GP clinic hours and with local interest groups and councillors who meet in the evenings - to say nothing of the frequent (and very constructive) meetings I have with clinicians and managers from our provider Trusts at pretty anti-social hours. The hours, as a result, are long, but what's needed to get the commissioning job done. Sorry if that doesn't fit with the cliches.
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Anonymous | 30-Sep-2011 12:05 pm
anon 10.51
Cliches tend to have a basis in fact. You're the first person I've come across in 20 years in the NHS who disputes that generally speaking working in the acute sector is more demanding than working in commissioning in terms of working hours - it's simply the nature of the beast. I've worked in both and am perfectly happy to be a commissioner now and sacrifice the financial advantages of an acute role for the extra time i'm able to spend doing stuff outside work. Clearly that's my choice, there will be those who see things differently. At the PCT where I work in London people arrive at work between 9 and 9.30 and the office is largely empty by 5.30 - the same was always true of Health Authorites where I worked too - very different from working practice in the hospital sector. Perhaps a slightly calmer outlook would assist you with achieving a more efficient working practice.
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Anonymous | 30-Sep-2011 12:51 pm
Is this an agreement that GPs/Primary care staff work long hours, the fact of 7.30 and 18.00 meetings? I work in general practice and its well known that everyone is out of the PCT by 5.00, and don't even think of a Friday afternoon meeting!
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Anonymous | 30-Sep-2011 2:59 pm
Oh bless
Both Anon 12.05 and 12.51; believe what you will. My diary says otherwise. And by the way, I'm nowheading for a 3.30 Friday afternoon meeting with our Clinical leads. I think we'll all have to agree to disagree.
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Anonymous | 30-Sep-2011 3:14 pm
Anon 3.37 (I was Anon 12.12 - isn't this fun? I've left the NHS but am still haunted by the need to watch what I say where and to whom!)
Yes, absolutely - much like Richard, I've only been involved in coming in and doing short term bespoke work (mostly financial diagnostics/ turnaround); not the long term largely thankless daily grind of making difficult change happen, winning hearts and minds, taking a lot of flack from the public, the media, never mind vested interests. Like you say, I can't see the private sector in changing its consultancy model unless it's incentivised to do so (which begs the question why, but then you could ask that of most of the recent changes). As for the hours, I've worked at trusts and PCTs, and on balance it did feel like there was a difference, but it depends what your job was, who you worked for..... As for being in the private sector now, all I can say is that you work long hours for better money but you aren't at the mercy of the endless tsunami of policy changes. And also like Richard, many of us want to hang onto the values that made us want to work in the NHS in the first place.
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Anonymous | 30-Sep-2011 3:30 pm
Let's be honest there are very few examples of genuine commissioning. Most of it is just about signing the cheque for something we don't know much about (despite the data tsunami).
The rest of it is about building YANWANs because we don't trust the established institutions to spend all the money on the stuff we think (vaguely) that they should be spending it on.
YANWAN: yet another nurse with another name ... look what's happened to core community nursing!
Hardly surprising it's not sexy so go on, have an epiphany and read Deceit and Self-Deception by Robert Trivers.
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Anonymous | 4-Oct-2011 1:19 pm
I seem to have a different perspective to many. In the area I work it is generally perceived that PCT staff are about 1 grade higher for equivalent responsibility, and certainly work a more standard working day. I moved over to the acute sector on the same band (jumped when PCT abolishment was announced) and I definetley have a more demanding job now, in responsibility and volume. In the trust people in mid 8's band are considered very senior, and there are not that many of them and they are expected to be decision makers. In the PCT the routine commissioning manager were in the mid 8's, and one thing they never did was make a decision!
I cannot comment on the new world of CCG, but I do know of quite a few people getting a band higher in the new orgs. Perhaps they are simply the cream rising to the top in the new world??
I guess I have just joined the wrong acute trust and need to find one of these high paying ones!!
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Patrick Newman | 4-Oct-2011 2:53 pm
Those that take an heroic self denying stand on long unsocial meetings should ask your HR department if they can play you a copy of "Meetings Bloody Meetings" by John Cleese.
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Anonymous | 4-Oct-2011 4:17 pm
Patrick
I agree in principle - am a bit tired of machismo-ridden stand-offs. However, on a practical note here's work to be done and a rapidly dwindling number of us. Including those in HR. A circle that will be increasingly diffuicult to square.
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